Remapping Debate has a very, very sobering piece on antibiotic resistance, and what it means for the future of health care. Two graphs sum up the problem. The first shows the rise of antibiotic resistance in various common infections.

The second shows the decline in the approval of new antibiotics.

These are not two trends you want to see moving in opposite directions.

There are a lot of reasons for the decline of new antibiotics--the market incentives are hopelessly misaligned, we've already picked a lot of the low-hanging fruit, and we're using way more antibiotics than we should in both humans and in animals. But anything we do to reduce overusage actually makes the problem of new antibiotic development worse, because it reduces the potential profit. At any rate, there's no clear way to solve this terrible divergence.

I've been talking about this problem for a while, but I've mostly thought about things like the ear infections that would have left me deaf before the advent of penicillin, or people dying in childbirth. I didn't start to understand the radical implications that antibiotic resistance has for health care practice until I read the absolutely gripping Rising Plague, by an infectious disease specialist who points out just how much of modern medicine is dependent on being able to control bacterial infection.

•Without antibiotics, there would be very little elective surgery. Before sulfa drugs, surgery was a very serious business with a high risk that a patient might die of some complicating infection.

•Without antibiotics, forget organ transplants. The immune suppression would almost certainly be fatal in a pretty short time period. HIV would also be more dangerous.

•Without antibiotics, retirements would get shorter again. Before antibiotics, the average 60 year old who caught pneumonia was more likely than not to die of it than not. That's why they used to call pneumonia the "old man's friend". Nor is pneumonia the only potential killer.

•Without antibiotics, maternal mortality would be a lot higher. So would mortality from abortions, dramatically. While backalley abortions were horrible, and did kill people up until legalization, the theatrical figures thrown around by the pro-choice movement were mostly due to the lack of antibiotics, not the butchery of the freelance abortionists. Between 1936 and 1960, the number of deaths from abortions seems to have fallen by something between 80-95%. Looking strictly at mortality, you'd probably be much better off getting an illegal abortion with antibiotics than a legal one without.

•Neonates would also be much more likely to succumb to infection, since their immune systems are underdeveloped.

•Chronic infections can lead to various sorts of cancer (H. Pylori, the bacteria that causes ulcers, also causes stomach cancer). These would take more people before they got Alzheimer's.

•The severely disabled would have much shorter life spans. Without antibiotics, there would be no way to treat the bed sores, or the lung and urinary tract infections that are common for people with limited sensation or mobility.

•Strep and its evil cousins, scarlet and rheumatic fevers, would once again be a major killer and disabler of children.These are by no means all the problems, only the ones I can think of off the top of my head. What this means for health care costs is a lot more spending on infection--but a lot less spending on everything else. It wouldn't be crazy to see health care costs heading down if we didn't have a reliable means of germ control.

Of course, that's a world in which antibiotics mostly just don't work--and by the time that happens, if it happens at all, most of us will be dead. What happens in between now and then?

Trickier to say. Infectious mortality will go up, reducing our costs for longer, more expensive diseases--and making people less willing to undergo marginal surgeries.

On the other hand, when the first-line antibiotics fail, the second line means admitting people to the hospital for intravenous antibiotics. This is obviously much more expensive than giving them a pill, even if we make all the doctors take pay cuts and use the awesome monopsony power of the federal government to buy all our antibiotics at a discount. We might be able to worry less about those huge health care costs in 2060--but we might need to worry a lot more about our health care costs in the next twenty or thirty years.

The superbugs have not only gotten bad fast--from "not really an issue" in 1980 to a major problem today--but they seem to be getting badder faster, as they merrily borrow resistance-conferring genes from each other. Researchers now say they're seeing resistance show up in the lab, before they even put the stuff into people.

Of course, the most worrying thing is not the effect on the budget. It's the effect on the people. A world without antibiotics is a world of vast suffering and early death.

Update: Commenter jmgalanter notes

Oh, it gets even more depressing. You haven't even mentioned tuberculosis; the susceptible bacteria is hard enough to treat (6 months of three or four antibiotics). Now imagine multidrug resistant (MDR) or extensively drug resistant (XDR) bacteria. There are now even strains that are resistant against every anti-tuberculous antibiotic out there.

From the Wikipedia entry on TB:

One-third of the world's current population has been infected with Mycobacterium tuberculosis, and new infections occur at a rate of one per second. About 5-10% of these latent infections will eventually progress to active disease, which, if left untreated, kills more than half of its victims. Annually, 8 million people become ill with tuberculosis, and 2 million people die from the disease worldwide. In the 19th century, tuberculosis killed an estimated one-quarter of the adult population of Europe; and by 1918 one in six deaths in France were still caused by TB. By the late 19th century, 70 to 90% of the urban populations of Europe and North America were infected with M. tuberculosis, and about 40% of working-class deaths in cities were from TB. During the 20th century, tuberculosis killed approximately 100 million people. TB is still one of the most important health problems in the developing world.

This is a topic that needs more discussion. I can not believe our complacency. I for one will have to be tied down to a hospital bed to keep me in one. I know more people that have had hospital caused complications than I care to think about.

“We are losing our first-line antimicrobials,” she said Wednesday in her keynote address at the conference on combating antimicrobial resistance. “Replacement treatments are more costly, more toxic, need much longer durations of treatment, and may require treatment in intensive care units.”

Indeed, diseases that were once curable, such as tuberculosis, are becoming harder and more expensive to treat.

Chan said treatment of multidrug resistant tuberculosis was “extremely complicated, typically requiring two years of medication with toxic and expensive medicines, some of which are in constant short supply. Even with the best of care, only slightly more than 50 percent of these patients will be cured.”

The ambulance sped up to the red brick federal research hospital on June 13, 2011, and paramedics rushed a gravely ill 43-year-old woman straight to intensive care. She had a rare lung disease and was gasping for breath. And, just hours before, the hospital learned she had been infected with a deadly strain of bacteria resistant to nearly all antibiotics.

The hospital employed the most stringent and severe form of isolation, but soon the bacterium, Klebsiella pneumoniae, was spreading through the hospital. Seventeen patients got it, and six of them died. Had they been infected by the woman? And, if so, how did the bacteria escape strict controls in one of the nation’s most sophisticated hospitals, the Clinical Center of the National Institutes of Health in Bethesda, Md.?

What followed was a medical detective story that involved the rare use of rapid genetic sequencing to map the entire genome of a bacterium as it spread and to use that information to detect its origins and trace its route.

“We had never done this type of research in real time,” said Julie Segre, the researcher who led the effort.

The results, published online Wednesday in the journal Science Translational Medicine, revealed a totally unexpected chain of transmission and an organism that can lurk undetected for much longer than anyone had known. The method used may eventually revolutionize how hospitals deal with hospital-acquired infections, which contribute to more than 99,000 deaths a year.

“It could transform infection control in hospitals and in the community,” said Dr. Sharon J. Peacock, a clinical microbiologist at the University of Cambridge in England, who was not involved in the study. But she added a cautionary note: The challenge now is interpretation of the genetic data. Most hospitals do not have the expertise. They needed tools, perhaps Web-based, to do the data analysis. At first, the hospital was confident that it could contain bacteria that could easily kill other patients whose immune systems were weakened by disease, said Dr. Tara Palmore, deputy epidemiologist at the Clinical Center. The doctors knew the bacteria would be almost impossible to stop once they got into patients’ bloodstreams.

“It really is the proverbial superbug,” Dr. Palmore said.

So the hospital used an approach called enhanced contact isolation. The patient was kept in a single room in intensive care. Everyone who entered had to wear masks and gloves. Every piece of equipment that touched the patient had to be disinfected. And items like blood pressure cuffs and stethoscopes that could not be disinfected were thrown away.

After 24 hours, the woman was moved to a regular private room. For her entire stay, she could walk in the hallway only if no one else was around and if she wore a gown and gloves. For physical therapy, she could use only equipment that was dedicated to her.

A month after she arrived, she was discharged. It seemed no one had picked up the bacteria. Everyone breathed a sigh of relief.

But on Aug. 5, lab technicians found the bacterium in the trachea of a man who had never been in the same area as the infected woman.

“We were worried that he could have gotten it from that first patient, but we just didn’t see how that was possible,” Dr. Palmore said. “That was when we first realized the limit of traditional culturing methods.”

The lab results could not tell the hospital whether the man had been infected by the woman or had an unrelated superbug.

But on Aug. 15, another patient tested positive for the micro-organism, and another on Aug. 23. About a patient a week was turning up positive for K. pneumoniae.

Dr. Segre, a genome researcher, proposed sequencing the entire genome of the first patient’s bacterium and comparing it with the genome sequences of bacteria from other infected patients. That could enable scientists to detect minute genetic changes that were the bacterium’s fingerprints. And they could use that knowledge to track the chain of infection.

When the first bacterial genome was sequenced, in 1995, it took three years. This time, researchers did it in just a couple of days.

Sequencing revealed that all the K. pneumoniae originated from the first patient, who transmitted the bacteria from her lung and throat on three occasions.

The woman’s lung bacteria differed from those in her throat by seven DNA base pairs out of six million — a chance occurrence that allowed the researchers to not only identify her bacteria in other patients but to know where they came from.

It showed the chain of transmission was more complex than anyone had anticipated. Patients were not infected in the order that they appeared to acquire the bacterium. It had smoldered in many of them, below the level of detection with the usual smears from the groin and throat.

The most surprising was Patient 4. He tested positive six weeks after the first patient left the hospital and died soon after, though not directly because of the infection. But this man had lymphoma, and it was thought that someone with a disease like that, which weakens the immune system, would have become ill within days.

“Suddenly seeing this long latency period was very worrisome,” Dr. Segre said.

The doctors were left with a mystery. How did the bacteria travel from the first patient to the others? The hospital staff had been scrupulous about hand-washing, isolated patients who had the bacteria in a separate intensive care unit and had a staff member there 24 hours a day to watch as staff members and visitors washed their hands and put on gowns and gloves. When researchers looked for the bacteria on staff members’ hands, they found none.

But they discovered the bacteria in a respirator that had been used by a patient who had the bacteria in his body but had not gotten ill. The respirator had been cleaned, but the disinfecting procedure had failed. The bacteria were also in the sink drains after the rooms had been cleaned. The hospital ended up removing plumbing to get rid of the bacteria.

The hospital finally controlled the outbreak by doing periodic rectal swabs of all patients and looking for the bacteria, a method that requires special equipment but that finds the bacteria even when they are undetectable in swabs from the groin and throat. The doctors also undertook the difficult task of telling patients about the outbreak, including the first woman whose infection ultimately killed six other people,

“They were understandably upset,” Dr. Palmore said. She apologized to one man.

“He in some way was still not satisfied,” Dr. Palmore said. “How could you be?”.